January 25, 2013

Probably no job is harder than a counsellor’s, especially when it comes to disclosing a client’s HIV status. On the other hand, no amount of counselling can be enough to prepare someone for sad news. But 30-year-old Josephine Nakato defied the odds.

Four years ago, Nakato learnt she was HIV-positive. “I was not surprised by the results because for years I had earned a living from prostitution,” she confesses.

“The ailment had gnawed me; I had lost weight, had a rash all over my body and sore lips. But my health has improved since I started taking ARVs.”

Nakato, however, regrets that quite often, the time she takes her ARVs coincides with the time most of her clients seek her services.

“I briefly sneak out to the latrine to take my ARVs,” she says.

Nakato says when she first went to The AIDS Support Organisation (TASO) in Tororo district, about 10 young sex workers at the Malaba border would die of HIV/AIDS every month.

However, today, the deaths have reduced because many have embraced positive living.

HIV/AIDS high at the border

Yosiya Ogwang, an opinion leader in Obore village, Malaba town council, says Tororo and Busia have a high number of people living with HIV because the districts not only lie at the border area separating Uganda and Kenya, but the two districts also host the official custom entry points.

However, because of the elaborate clearance system at the customs office, often the delays in cargo clearance compel the drivers and turn-boys to spend nights at the border.

“The daily influx of drivers and turn-boys has for years promoted promiscuity around these places,” an official at the Uganda Revenue Authority, who preferred anonymity, says.

In addition, five other commercial sex dens have cropped up in Tororo as a result of the vibrant cement industry.

Five people have so far died while 30 others are admitted to different health centres as a result of a strange disease that has hit Mubende District.

According to residents, the disease that broke out a few weeks ago, causes heat around the chest and itching in the neck, and within a few hours, the patient starts vomiting and bleeding through the nose and the mouth. It also causes diarrhoea and a high fever.

Residents claim that the disease is as a result of witchcraft, since some of the patients have sought help from witch doctors and allegedly felt better.

The district health officer, Dr Wilson Mubiru, explained that the first patients registered with symptoms of the disease suspected they were suffering from Ebola.

“We have forwarded blood tests to the Uganda Virus Research Institute (UVRI) in Entebbe. Although we are yet to get the results, we highly doubt whether this is Ebola,” Dr Mubiru said.

Ministry of Health permanent secretary, Dr Asuman Lukwago, yesterday confirmed that cases of the strange illness had been reported to them, saying they were following it up.

Outbreaks

Just last week, Uganda was again declared Ebola-free after an outbreak in Luweero District killed four people.

However the government is still grappling with the nodding syndrome disease in northern Uganda that has killed scores of children and left others helpless.

The year 2013 bodes ill for Pakistan as far as measles is concerned as the World Health Organization (WHO) has reported 94 measles outbreaks throughout the country in the first three weeks of January alone.

The WHO report has described the situation in Pakistan as alarming due to a steady increase in measles cases and deaths.

The WHO reports 25 measles outbreaks in Punjab over the last three weeks, exposing the provincial government, which has trumpeted much about the ‘normal situation’ in the province. Punjab health officials have denied measles outbreak in any part of the province so far. According to the WHO, Punjab has the second highest number of measles outbreaks after Balochistan, where 33 outbreaks were reported in the first three weeks of 2013.

The WHO report says that measles claimed lives of 103 children throughout the country from Jan 1 to Jan 19. Of them, 66 children died in Sindh, 33 in Balochistan and seven in Punjab.

The WHO and the Punjab Health Department have consensus that seven deaths took place in the province during the last three weeks, but the district where they reported these death are different.

Special Assistant to Chief Minister on Health Khwaja Salman Rafique says in Punjab one child died in the Gujranwala district, one in the Kasur district and five in the Rajanpur district, while the WHO reports one death each in Lahore, Dera Ghazi Khan and Rahim Yar Khan and two each in Bhakkar and Rawalpindi. If the data of both health department and WHO is correct, the death toll in Punjab has reached 14.

The WHO report says that transmission of measles virus to healthy children increased manifold in January 2013 compared to the same month last year. According to the report, 2,447 measles cases were reported during last three weeks, while only 447 cases were reported in January 2012. The report warns of spread of the disease if stakeholders do not take it seriously.

In the first three weeks of January, 1211 measles cases were reported in Sindh, 290 in Khyber Pakhtunkhwa and 483 in Balochistan.

“The highest number of measles cases and deaths was reported in the Naseerabad district (220 cases and 20 deaths), followed by Jaffarabad (73 cases and five deaths), Killa Saifullah (39 cases and four deaths) and Jhal Magsi (23 cases and one death).”

According to the WHO, the monthly trend of measles cases in 2012 shows that the number of cases started increasing in April 2012 and reached the peak in May-June 2012. The second upward trend started in October 2012.

I can't find the WHO report mentioned in the story, but here is WHO's latest fact sheet on measles, published on January 25. It's disturbing: A disease that North Americans and Europeans hardly think about is killing 18 children every hour of every day.

Cambodia's health ministry today announced three new H5N1 avian influenza cases, two of them fatal and all located in the southwestern part of the country with exposure to poultry, according to a joint statement from the ministry and the World Health Organization (WHO).

The cases are the world's first to surface in 2013 and push the number of H5N1 infections in Cambodia since 2005 to 24, which includes 21 deaths.

Rapid response teams are identifying and monitoring the patients' close contacts, exploring if there were any epidemiologic links between the three cases, and conducting educational campaigns about the virus in villages, according to the statement.

Influenza-Associated Hospitalizations: A cumulative rate for the season of 22.2 laboratory-confirmed influenza-associated hospitalizations per 100,000 population was reported. Of all hospitalizations, 50% were among adults 65 years and older.

Outpatient Illness Surveillance: The proportion of outpatient visits for influenza-like illness (ILI) was 4.3%; this is above the national baseline of 2.2%. All 10 regions reported ILI above region-specific baseline levels. Twenty-six states and New York City experienced high ILI activity; 14 states experienced moderate activity; 9 states experienced low activity; 1 state experienced minimal activity, and the District of Columbia had insufficient data.

Geographic Spread of Influenza: Forty-seven states reported widespread geographic influenza activity; 2 states reported regional activity; the District of Columbia and one state reported local activity; Guam reported sporadic influenza activity, and Puerto Rico and the U.S. Virgin Islands did not report.

For example, how did H5N1 jump from 4 cases and 4 deaths in China and Vietnam in 2003, to 46 cases and 32 deaths in Thailand and Vietnam in 2004? And how did it then double to 98 cases and 43 deaths in five countries by 2005? Your guess is as good as mine, and probably better.

One question that's bothered me is why Cambodian H5N1 has been so rare and so lethal, compared even to Indonesia and China. The first 7 cases in Cambodia (2004-2007) were all fatal. In 2008 and 2009, Cambodia had just 1 case per year, and both patients lived. Another single case appeared in 2010, and was fatal. Then in 2011 8 persons contracted H5N1 and all died. Three more cases appeared in 2012, and again all were fatal.

So until today's announcement, Cambodia had seen just 21 cases in 8 years, but its case fatality rate was 90 per cent. Today's announcement brings the CFR down to 87.5 per cent, still a shocking rate. (Indonesia's CFR, based on 192 cases and 160 deaths, is 83 per cent.)

Is that the result of people being slow to seek medical aid, or is Cambodia's local H5N1 strain just that much nastier? I have no idea.

It's Friday night in Europe, but WHO in Geneva will probably update its website sometime Saturday morning. I hope the report helps to answer these questions.

Another two A/H1N1 flu-related deaths were reported last week, bringing the virus' death toll to five this year in Beijing, the city's health authorities said Friday.

From Jan. 14 to 20, two deaths resulting from the A/H1N1 virus were reported as the city entered peak flu season, but a massive outbreak is unlikely, said Xie Hui, director of the disease control department of the Beijing Municipal Health Bureau.

A/H1N1 flu-related deaths have been reported every week this month in Beijing. In addition to the A/H1N1 virus, the A/H3N2 virus is also currently spreading, according to relevant epidemic pathogen tests.

The A/H1N1 flu outbreak peaked in 2009. More than 120,000 A/H1N1 flu cases were recorded that year in the Chinese mainland, with 648 cases resulting in death.

Wang Quanyi, head of the epidemic prevention institute under the Beijing Centers for Disease Control and Prevention, said people were not yet immune to the A/H1N1 virus in 2009, when the virus spread globally.

Now that the A/H1N1 virus has become an ordinary seasonal flu and people have become immune, an outbreak is very unlikely, according to Wang.

The recent series of fatal attacks on teachers and public health workers associated with vaccination programmes in Pakistan (Jan 5, p 1) have been utterly devastating. These killings have shattered the lives of the families of those who died serving their communities with basic health services. They will also undermine the effectiveness of vital public health interventions through disrupted delivery, reduced confidence, and a demoralised workforce.

Yet although these events have placed the spotlight on Pakistan, and the new form of aggressive propaganda against “western” public health initiatives, they are indicative of a global problem, particularly in places with armed conflicts, which requires a global response.

First, we must insist on zero tolerance of violence against health workers, and multilateral agencies such as WHO should champion the cause. Although WHO has identified the importance of protecting health facilities in conflict zones, any strategy or recommendations on protecting public health workers against militant attacks is hard to find.

Second, donor agencies should continue to insist on reasonable protection for health workers, including programmes to prevent violence. Commissioners and managers of health services should be required to include the protection of health workers in their responsibility for delivering public health services. Health workers, by their very nature, will often want to take risks to provide services to the poor. Although we have no wish to stifle this altruistic spirit, to expose health workers to risks that could be mitigated could be seen as criminal, or at least immoral.

Third, further research is needed into effective actions to prevent violence against health workers, especially in resource-poor settings. In the otherwise excellent World report on violence and health, health workers are seen as part of the response to violence and their own need to be protected is not adequately addressed.

The discussions about gun control and gun violence cannot and should not be restricted. The executive orders issued by President Obama safeguard the existing lines of communication between patients, doctors, and law authorities. Furthermore, the input from federally funded agencies via high-quality and politically neutral research is essential. Progress here will likely be slow and incremental—for example, the CDC has indicated that no new funding will go toward gun-related research until 2014. It is crucial, however, that America uses the momentum generated by the terrible events of the past few years to keep a conversation about gun control, and the prevention of gun violence, going.